Multidisciplinary management of the bone and joint infection complicating treatment of an open fracture of the lower limb.

Bone and joint infections (BJI) of the lower limb can cause functional sequelae and in some cases have an impact on patient's life prognostic. One of the main objectives of multidisciplinary consultation team meetings (MTM) in the treatment of bone and joint infections is to provide an appropriate medical-surgical care, pooling skills of different organ specialists: infectious disease physicians, microbiologists, orthopedic surgeons and plastic surgeons. Treatment is based on aggressive debridement, bone stabilization, adequate antibiotic therapy, long-term coverage of the loss of skin substance and close clinical monitoring. The authors present their multidisciplinary diagnostic and therapeutic approaches to BJI complicating an open fracture at a referent center in the management of complex bone and joint infections.

Multidisciplinary team meeting for complex bone and joint infections diagnosis: The PHICTOS study.

BACKGROUND: In France, the most severe bone and joint infections (BJI), called "complex" (CBJI), are assessed in a multidisciplinary team meeting (MTM) in a reference center. However, the definition of CBJI, drawn up by the Health Ministry, is not consensual between physicians. The objective was to estimate the agreement for CBJI classification. METHODS: Initially, five experts from one MTM classified twice, one-month apart, 24 cases as non-BJI, simple BJI or CBJI, using the complete medical record. Secondly, six MTMs classified the same cases using standardized information. Agreements were estimated using Fleiss and Cohen kappa (κ) coefficients. RESULTS: Inter-expert agreement during one MTM was moderate (κ=0.49), and fair (κ=0.23) when the four non-BJIs were excluded. Intra-expert agreement was moderate (κ=0.50, range 0.27-0.90), not improved with experience. The overall inter-MTM agreement was moderate (κ=0.58), it was better between MTMs with professor (κ=0.65) than without (κ=0.51) and with longer median time per case (κ=0.60) than shorter (κ=0.47). When the four non-BJIs were excluded, the overall agreement decreased (κ=0.40). CONCLUSION: The first step confirmed the heterogeneity of CBJI classification between experts. The seemingly better inter-MTM than inter-expert agreement could be an argument in favour of MTMs, which are moreover a privileged place to enhance expertise. Further studies are needed to assess these results as well as the quality of care and medico-economic outcomes after a MTM.

[Septic arthritis after arthroscopic cruciate ligament reconstruction: in vitro comparison of the behavior of two types of interference screws towards the Staphylococcus aureus adherence]. / Arthrite septique après ligamentoplastie du pivot central sous arthroscopie : comparaison in vitro du comportement de deux types de vis d'interférence vis-à-vis de la fixation du Staphylococcus aureus.

PURPOSE OF THE STUDY: We report the results of an experimental study designed to investigate the behaviour of two types of interference screws (bioabsorbable versus titanium) in a context of Staphylococcus aureus infection. The main objective was to study one of the possible sources of failure for the treatment of acute arthritis of the knee after arthroscopic reconstruction of the cruciate ligament. MATERIAL AND METHODS: We used six interference screws made of titanium and six bioabsorbable screws (PLLA-PDLLA). All screws measured 9mmx25mm, were cannulized and sterilized. These screws were submitted to a protocol elaborated in cooperation with the bacteriologists. After contamination with a strain of S. aureus, the screws were washed four times in saline solution to eliminate germs adsorbed in the aqueous phase. The last step was trypsination to detach germs remaining fixed onto the screws and contained in the biofilms of glycocalix. A germ count was made after each step. For each screw, we determined the difference (Delta) corresponding to the number of germs really adherent to the screw. Mann-Whitney analysis was performed. RESULTS: On average, the germ count in the aqueous phase was 0.0855.10(5)/ml for the titanium screw versus 0.223.10(5)/ml for the bioabsorbable screw. The mean count of germs fixed in the biofilm (mean Delta) was 17.695+/-3.88.10(5) for the titanium screw and 45.86+/-3.61.10(5) for the bioabsorbable screw. The difference was statistically significant (p=0.0039). DISCUSSION: Our experimental results support the efficacy of abundant arthroscopic lavage in a context of infection, confirming the results of very recent studies. However, irrespective of the type of material used, bioabsorbable screws are more prone to persistent microbial adherence than titanium screws. It is hypothesized that the hydrophilic, more porous microstructure of bioabsorbable screws favors bacterial adherence. In practice, this implies that arthroscopic washout must be as abundant and as complete as possible, yet may not be sufficient to clean the entire surface of potentially contaminated screw positioned deep in a bony tunnel.

[Tibial valgus osteotomy]. / Ostéotomie tibiale de valgisation.

The tibial valgus osteotomy whatever its technique has a survival rate of about 85 % to 10 years, if we consider the reoperation as a criterion of failure, with a confidence index at 78%. The age, weight, sex and functional signs have no impact on the outcome. We have found no evidence in the preoperative radiographic assessment, neither the medial pinch, or varus epiphyseal neither varisant gap, which could be a failure and a reoperation before the tenth year. Good results were observed significantly when there is an over-valgus at least 3 degrees of global axis of the lower limb. This corresponds to a valgus epiphyseal by more than 2 degrees . The substantial reduction in the gap varisant that lowers the overall time varisant below 200 kg cm provides the same positive results. The outcome will depend directly on the accuracy of the calculation of the preoperative correction performed and the quality of surgical achievement. Because of the need for precision, navigation technique appears as reliable, simple which makes it also possible to monitor the front slope and tibial rotation induced. The osteosynthesis must be stable and rigid to avoid postoperative loss of correction.

FCN-based approach for the automatic segmentation of bone surfaces in ultrasound images.

PURPOSE: A new algorithm, based on fully convolutional networks (FCN), is proposed for the automatic localization of the bone interface in ultrasound (US) images. The aim of this paper is to compare and validate this method with (1) a manual segmentation and (2) a state-of-the-art method called confidence in phase symmetry (CPS). METHODS: The dataset used for this study was composed of 1738 US images collected from three volunteers and manually delineated by three experts. The inter- and intra-observer variabilities of this manual delineation were assessed. Images having annotations with an inter-observer variability higher than a confidence threshold were rejected, resulting in 1287 images. Both FCN-based and CPS approaches were studied and compared to the average inter-observer segmentation according to six criteria: recall, precision, F1 score, accuracy, specificity and root-mean-square error (RMSE). RESULTS: The intra- and inter-observer variabilities were inferior to 1 mm for 90% of manual annotations. The RMSE was 1.32 ± 3.70  mm and 5.00 ± 7.70 mm for, respectively, the FCN-based approach and the CPS algorithm. The mean recall, precision, F1 score, accuracy and specificity were, respectively, 62%, 64%, 57%, 80% and 83% for the FCN-based approach and 66%, 34%, 41%, 52% and 43% for the CPS algorithm. CONCLUSION: The FCN-based approach outperforms the CPS algorithm, and the obtained RMSE is similar to the manual segmentation uncertainty.

Reproducibility of length measurements of the lower limb by using EOS™.

BACKGROUND: Lower-limb discrepancy following total hip arthroplasty is the third-most common reason for patient dissatisfaction in orthopaedic surgery. Therefore, accurate planning and evaluation methods are mandatory. The main aim of this study was to evaluate the reliability of the EOS™ system by establishing and comparing the reproducibility of lower-limb automatic and manual 3D measurements. We hypothesized that the reproducibility of the lower-limb measurements is similar regardless of the method used and with an agreement higher than 0.95 for the length parameters. MATERIALS AND METHODS: This study utilized an EOS radiological database of 112 patients. Two independent observers performed two rounds of lower-limb measurements twice, either in manual 3D or automatic 3D mode. The intra- and inter-observer reproducibility was evaluated by the calculation of the intra-class coefficient for each measurement method. The methods were then compared. RESULTS: The intra- and inter-observer reproducibility for length measurements found with the manual and automatic 3D methods was always > 0.98. There was no significant difference in the reproducibility between the two measurement modes, with the exception of the offset, hip-knee-shaft, and neck-shaft angles. CONCLUSION: Our results indicate a very good reproducibility of EOS™ length measurement, regardless of the method used. Automated 3D mode is preferred for the collection of angular and offset measurements. Furthermore, manual mode measurements are not affected by surgical history. Level of evidence IV.

[Computer assisted orthopedics surgery]. / L'expérience de la navigation chirurgicale dans l'ouest.

Computer-assisted surgery has become commonplace in orthopedic surgery. The number of applications grows steadily as does the number of patients benefiting from these new techniques. The hearty debates heard when these techniques were first introduced have now given way to more evidence-based evaluation. Our objective here is to continue this approach by presenting our six-year experience with navigation. We will not discuss the theoretical background of these technologies nor attempt to present an exhaustive review of the literature but rather focus attention on surgical skills acquired by a group of surgeons working in a wide range of areas. The common point is that all have now integrated computer-assisted navigation into their routine surgical practices including: a) first-intention and revision knee arthroplasty; b) hip arthroplasty; c) anterior cruciate ligament surgery; d) proximal tibial osteotomy; e) shoulder arthroplasty. We will terminate this round table with a presentation of future technological advances and propose our advice for an increasingly widespread use of these new techniques.

Influence of experience on intra- and inter-observer reproducibility of the Crowe, Hartofilakidis and modified Cochin classifications.

INTRODUCTION: A previous study demonstrated that the reproducibility of the Crowe (Cr), the Hartofilakidis (Ha) and the modified Cochin (Co) classifications were comparable. However, there were differences with a trend that suggested the influence of experience. Therefore, we performed a prospective study to investigate whether experience influenced the reproducibility of the commonly used developmental dysplasia of the hip (DDH) classifications. HYPOTHESIS: The hypothesis was that the intra- and inter-observer reproducibility scores would be higher in the senior group than the junior group, and particularly for the modified Co classification. METHODS: Four seniors and four residents classified 104 A/P pelvic radiographs (200 hips) two times using the Cr, Ha and Co classification systems. RESULTS: For intra-observer reproducibility, the average weighted concordance coefficients [95% confidence intervals] were for the senior and the junior groups: 92.2 [88.6-95.7] and 92.6 [87.9-97.2] for Cr, 92.1 [88.7-94.6] and 92.0 [87.7-96.3] for Ha, 94.2 [91.8-96.6] and 94.1 [91.5-96.6] for Co. The average weighted Kappa (95% confidence intervals) were 0.8 [0.71-0.88] and 0.79 [0.68-0.89] for Cr, 0.77 [0.74-0.81] and 0.75 [0.62-0.88] for Ha, 0.82 [0.76-0.89] and 0.80 [0.74-0.87] for Co. The junior inter-observer reproducibility multi-rater Kappa (list A:list B) were 0.57:0.50 (Cr), 0.47:0.53 (Ha), 0.42:0.42 (Co). Senior multi-rater Kappa were 0.53:0.49 (Cr), 0.40:0.34 (Ha), 0.40:0.43 (Co). CONCLUSIONS: Contrary to our hypothesis, the experience of the observer did not affect the intra- and inter-observer reproducibility of the three classification systems.

Design and evaluation of an actuated knee implant for postoperative ligament imbalance correction.

In Total Knee Arthroplasty (TKA), the collateral ligament tensioning stage cannot be standardised for all patients and relies heavily on the surgeon's experience and perception. Intraoperative inaccuracies are practically unavoidable and may give rise to severe postoperative complications, leading to the need for revision surgery already a few years after primary TKA. This work proposes a novel instrumented tibial component able to detect collateral ligament laxity conditions right after primary TKA and, if needed, to compensate for them in the postoperative period. A miniaturised actuation system, designed to be embedded in the tibial baseplate, was initially evaluated by means of 3D simulations and then fabricated as a full-scale prototype. Stability and force sensors tests carried out on a knee simulator allowed to assess the effectiveness of the proposed design under normal working conditions and provided valuable insights for future work and improvements.

Comparison of the reliability of leg length and offset data generated by three hip replacement CAOS systems using EOS™ imaging.

INTRODUCTION: Computer-assisted orthopaedic surgery (CAOS) theoretically will help to optimise total hip arthroplasty (THA) results. Although CAOS systems have become more sophisticated, they are not widely used, partially because of their suspect reliability. To assess reliability of these systems, we carried out a study with multiple objectives in mind: (1) establish and compare the accuracy of the leg length (LL) measurement from three CAOS systems; (2) analyse the correlation of LL and offset data generated by these CAOS systems with those of the EOS™ imaging system; (3) determine if the goals of leg length restoration with ±2 and ±5 mm were achieved; (4) evaluate why certain cases fails. HYPOTHESIS: The three CAOS systems have the same accuracy for LL, and their error is less than or equal to 0.6mm. MATERIAL AND METHODS: We retrospectively studied 106 cases of primary THA where preoperative and postoperative measures of leg length had been performed with an EOS™ imaging system. The cases were placed in three groups, depending on which CAOS system had been used: group A (Amplivision™, amplitude), group B (Hip Express™, Brainlab), group P (THS™, Praxim). The accuracy of the leg length data was calculated by finding the difference between the data from each CAOS system and the gold-standard EOS measurements. RESULTS: The leg length accuracy was -0.846 [-5 to 9], -0.675 [-9 to 18] and 0.542 mm [-5 to 13], respectively for groups A, B and P. The accuracy was significantly lower in group A than B (P=0.044) and group P (P=0.038). The Pearson correlation coefficient for CAOS and EOS measurements was 0.189, 0.701 and 0.891 for leg length and 0.668, 0.202 and 0.680 for offset, for groups A, B and P, respectively. No difference between groups were observed relative to the leg length objectives being achieved within ±2 mm (P=0.61) and ±5 mm (P=0.314). There were no differences in terms of the number of CAOS failures: three in group A, one in group B and three in group P (P=0.06). CONCLUSION: The Praxim™ and Brainlab™ CAOS systems had similar accuracy for leg length measurements, and both were better than the Amplitude™ system. Only the Praxim™ had an error of less than 0.6mm. All the CAOS systems had values less than 1mm, which is considered excellent. LEVEL OF EVIDENCE: Level IV, retrospective study.

Can computer-assisted surgery help restore leg length and offset during THA? A continuous series of 321 cases.

INTRODUCTION: Total hip arthroplasty (THA) can bring about complications - particularly leg length differences - that are becoming increasingly litigious. Computer-assisted orthopedic surgery (CAOS) can help optimize the procedure, but its ability to effectively restore leg length is controversial. As a consequence, we carried out a study to determine: (1) its contribution to meeting leg length and offset objectives, (2) its reliability, by evaluating the correlation between radiological and navigation data, (3) its safety, by evaluating navigation-specific and non-specific complications. HYPOTHESIS: CAOS will help to restore leg length within ± 5 mm in more than 80% of cases. MATERIAL AND METHODS: A series of 321 continuous cases of cementless THA implanted through the posterolateral approach using CAOS was analyzed retrospectively. With a minimum 1 year follow-up, we evaluated whether the leg length and offset goals were achieved, how well the navigation and radiology data were correlated and whether navigation-specific and non-specific complications occurred. Based on our hypothesis that 80% of patients would have less than 5 mm leg length difference and the null hypothesis (PA = P0) with an alpha of 0.05, 200 observations were required to achieve a power of 90%. RESULTS: The leg length and offset objectives were achieved in 83.3% and 88% of cases, respectively. Twenty-two patients required a heel wedge to compensate for leg length differences. The correlation between the radiology and surgical navigation data was satisfactory - the Pearson coefficient was 0.79 for length and 0.74 for offset. Intraoperative and postoperative complications or adverse events were found in 14.6% of cases; these were specific to CAOS in 12.1% of cases and non-specific in 2.5% of cases. CONCLUSION: This study shows the relevance of CAOS for achieving preoperative leg length objectives, with good correlation between navigation and radiology data, and without major complications. LEVEL OF EVIDENCE: IV - retrospective study.

Modeling and analysis of 3-D elongated shapes with applications to long bone morphometry.

Presents a geometric model to be used as a framework for the description and analysis of three-dimensional (3-D) elongated shapes. Elongated shapes can be decomposed into two different parts: a 3-D curve (the central axis) and a 3-D surface (the straight surface). The central axis is described in terms of curvature and torsion. A novel concept of torsion image is introduced which allows the user to study the torsion of some relevant 3-D structures such as the medulla of long bones, without computing the third derivative. The description of the straight surface is based on an ordered set of Fourier Descriptors (FDs), each set representing a 2-D slice of the structure. These descriptors possess completeness, continuity, and stability properties, and some geometrical invariancies. A polar diagram is built which contains the anatomical information of the straight surface and can be used as a tool for the analysis and discrimination of 3-D structures. A technique for the reconstruction of the 3-D surface from the model's two components is presented. Various applications to the analysis of long bone structures, such as the ulna and radius, are derived from the model, namely, data compression, comparison of 3-D shapes, segmentation into 3-D primitives, and torsion and curvature analysis. The relevance of the method to morphometry and to clinical applications is discussed.

A characterization of the geometric architecture of the peritalar joint complex via MRI: an aid to the classification of foot type.

The purpose of this work is to study the architecture of the rearfoot using in vivo MR image data. Each data set used in this study is made of sixty sagittal slices of the foot acquired in a 1.5-T commercial GE MR system. We use the live-wire method to delineate boundaries and form the surfaces of the bones. In the first part of this work, we describe a new method to characterize the three-dimensional (3-D) relationships of four bones of the peritalar complex and apply this description technique to data sets from ten normal subjects and from seven pathological cases. In the second part, we propose a procedure to classify feet, based on the values of these new architectural parameters. We conclude that this noninvasive method offers a unique tool to characterize the 3-D architecture of the feet in live patients, based on a set of new architectural parameters. This can be integrated into a set of tools to improve diagnosis and treatment of foot malformations.

An in vivo analysis of the motion of the peri-talar joint complex based on MR imaging.

The purpose of this work is to characterize the three-dimensional (3-D) motion of the peritalar joint complex in vivo using magnetic resonance imaging (MRI). Each image data set utilized in this study is made of 60 longitudinal MR slices of the foot in each of eight positions from extreme pronation to extreme supination. We acquired and analyzed ten such data sets from normal subjects, seven data sets from pathological joints and two postoperative data sets. We segmented and formed the surfaces of the calcaneus, talus, cuboid and navicular from all data sets. About 30 geometrical parameters are computed for each joint in each position. The results present features of normal motion and show how normal and abnormal motion can be distinguished. They also show the consequences of surgery on the motion. This non- invasive method offers a unique tool to characterize and quantify the 3-D motion of the rearfoot in vivo from MR images.

3D MR image analysis of the morphology of the rear foot: application to classification of bones.

The purpose of this work is to characterize the three-dimensional (3D) morphology of the bones of the rear foot using MR image data. It has two sub-aims: (i) to study the variability of the various computed architectural measures caused by the subjectivity and variations in the various processing operations; (ii) to study the morphology of the bones included in the peritalar complex. Each image data set utilized in this study consists of sixty sagittal slices of the foot acquired on a 1.5 T commercial GE MR system. The description of the rear foot morphology is based mainly on the principal axes, which represent the inertia axes of the bones, and on the bone surfaces. We use the live-wire method [Falcao AX, Udupa JK, Samarasekera S, Shoba S, Hirsch BE, Lotufo RA. User-steered image segmentation paradigms: live wire and live lane. Proceedings of the Society of Photo-optical Instrumentation Engineers 1996;2710:278-288] for segmenting and forming the surfaces of the bones. In the first part of this work, we focus on the analysis of the dependence of the principal axes system on segmentation and on scan orientation. In the second part, we describe the normal morphology of the rear foot considering the four bones namely calcaneus, cuboid, navicular, and talus, and compare this to a population from the upper Pleistocene. We conclude that this non-invasive method offers a unique tool to characterize the bone morphology in live patients towards the goal of understanding the architecture and kinematics of normal and pathological joints in vivo.

Bone morphing: 3D morphological data for total knee arthroplasty.

OBJECTIVE: The clinical outcome of a total knee arthroplasty (TKA) is mainly determined by the accuracy of the surgical procedure itself. To improve the final result, one must take into account (a) the alignment of the prosthesis with respect to the mechanical axis, and (b) the balance of the soft tissues. Therefore, morphologic data (such as the shape of the epiphysis) and geometric data are essential. We present a new method for performing TKA based on morphologic and geometric data without preoperative images. MATERIALS AND METHODS: The global method is based on the digitization of points with an optical 3D localizer. For the morphologic acquisitions, we use a method based on the registration of sparse point data with a 3D statistical deformable model. To build the mechanical axis, we use a kinematics method for the hip center and digitization of anatomical landmarks for the ankle centers. The knee center is not determined by digitization or kinematics of the knee, as this would not be accurate. The surgical planning relies totally on the soft-tissue balance, which is the key issue for a good kinematics result. RESULTS: We have used this system for 6 months in a randomized clinical trial involving 35 patients to date. For the first 11 patients that could be measured in the navigation group, the postoperative frontal alignment was within the range of 180 +/- 3 degrees. Fluoroscopic assessment of the soft-tissue balancing will be performed at the conclusion of an extended 2-year study to evaluate the results from a functional point of view. CONCLUSION: Bone Morphing is an accurate, fast, and user-friendly method that can provide morphologic as well as geometric data. We have introduced the important notion of soft-tissue balancing into the intraoperative planning step to optimize the kinematics as well as the anatomy. Therefore, this method should be considered as an alternative to the CT-based method.

[Free musculo-tendinous flap stabilization-interposition of the palmaris longus tendon after trapezium surgery in rhizarthrosis]. / Stabilisation--interposition par greffon libre musculo-tendineux de long palmaire après trapézectomie dans la rhizarthrose.

Complete resection of the trapezium combined with interposition and ligament reconstruction with flexor carpi radialis remains the author's preferred method thumb basal joint arthritis the surgical treatment. Elevating half of the tendon takes a long time and is not so easy to perform. Using palmaris longus tendon with a fragment of muscle seemed to be more practical and quicker. It allowed simultaneously stabilization (tendon part) and an effective interposition (muscle part).

[Vascularized fibular transplant for avascular necrosis of the femoral head: 16 cases]. / Evolution anatomo-radiographique des nécroses avasculaires de la tête fémorale traitées par transplant fibulaire vascularisé. A propos de 16 cas.

PURPOSE OF THE STUDY: We report our experience with vascularized fibular transplant using the technique described by Urbaniak for the treatment of avascular necrosis of the femoral head. MATERIAL AND METHODS: Sixteen patients, mean age 39 years 4 months at surgery, were evaluated at mean 3 years 6 months follow-up (minimum 15 months). Mean pain score (analog visual scale) was 6.25/10. Mean Postel-Merle-d'Aubigné (PMA) function score was 12. The Ficat classification was grade 2A (n=9) or grade 2B (n=7). RESULTS: There were no cases of infection or migration of the fibula. The only complication at the donor site was one case of paresia of the long extensor of the hallux which resolved spontaneously. There were five failures which required a hip prosthesis (31%). Three failures occurred early during the first 18 months. Two were late. These patients had grade 2B (n=4) or grade 2A (n=1) necrosis. At last follow-up, eleven hips had not required prosthetic revision (69%). The pain score improved in 81% of patients: mean score=2.3. Nine patients were satisfied or very satisfied (81%). Among these eleven hips, function was good or excellent in eight (72%). Walking distance was improved in nine patients, unchanged in one and worse in one. Joint motion improved in nine patients, was unchanged in one and decreased in one. Nine patients resumed their full-time job. Mean sick leave was 13.3 months. Radiographically, only two of the initial Ficat grade 2A hips remained at this stage. Likewise only one of the three hips initially rated grade 2B remained at this stage. Overall radiographic results were: failure (n=5), worsening (n=9), stabilization and no improvement (n=2). Among the nine 2A hips, one was converted to a total hip prosthesis and five femoral heads remained spheric. Among the seven 2B hips, four were converted to a total hip prosthesis and two femoral heads collapsed. DISCUSSION: At mean follow-up (3.5 years), 69% of the hips had not required total hip arthroplasty. The grade 2A hips did better but the small sample size did not allow statistical comparison. There was a clear discordance between the clinical presentation and the radiographic findings among the hips which were not treated with a prosthesis: good function score, maintained occupational and daily life activities contrasting with unfavorable radiographic evolution. Results could be improved by detailed quantification of the lesion using 3D imaging and by associating intraoperative navigation.

[Controlled mobilisation after suture of extensor tendons of the hand. Apropos of 30 consecutive cases]. / Mobilisation assistée après suture des tendons extenseurs à la main. A propos de 30 cas consécutifs.

From January 1988 to May 1991, 30 patients (mean age: 27 years old; range: 15 to 45) sustained 57 tendon injuries in 49 fingers. They were treated by primary repair with assisted post-operative mobilisation by a dynamic splint. Adhesion of extensor apparatus rate was 12 p. cent but only one had a functional impairment. No other complications were noted. At the thumb level (3 out of 49 fingers) the Kapandji-test was respectively at 8.8 and 9/10 without any extensor lack. At the long fingers level TAM was excellent in 91 p. cent of cases, good in 4 p. cent, fair and poor in 2 p. cent. According to Allieu classification results were good and excellent in 9 p. cent of cases. These results were better when injury was localised to or up to zone 5 according to Verdan's classification, and when there was no associated bone nor articular injuries or cutaneous defects. Subjective results were less good (70 p. cent of satisfactory results) because of pain, grip strength lack or disability. Assisted mobilisation allowed intrinsic healing and avoided adhesion when application date and rehabilitation protocol were respected. It was more beneficial for distal and complex injuries.

Fracture of the distal part of the radius associated with severed ulnar nerve.

We report a case of a severed ulnar nerve after fracture of the distal part of the radius. The most likely hypothesis is stretching of the ulnar nerve fixed by Guyon's canal and severed on the sharp edge of the proximal radius. Although very rare, this lesion must be investigated particularly in cases with marked displacement, especially ulnar and/or volar.